Table of Contents
INTRODUCTION
Various imaging modalities are being used in the evaluation of patients with urinary tract abnormalities. Earlier, in such patients imaging of urinary tract abnormalities was primarily done by using intravenous urography (IVU). Now a days, IVU, ultrasonography (US), computed tomography (CT), magnetic resonance (MR) imaging, , cystoscopy, ureteroscopy, retrograde ureterography and pyelography are the various techniques being practiced for the assessment of patients with urinary complaints. IVU or retrograde ureterography and pyelography have wontedly been used to diagnose urothelial diseases.
Consistently non contrast CT is used to assess for calculi and hydronephrosis. Renal masses are generally interpreted with CT, US, or MR imaging . CT usually demonstrates pedunculated bladder disease, but flat tumors of the bladder are difficult to be identified with CT and thus cystoscopy remains the study of choice in evaluating for bladder malignancy.
Comprehensive evaluation of patients with a single examination is now possible with the arrival of spiral CT and MDCT in particular. CT urography can be performed with a combination of unenhanced, nephrographic-phase, and excretory-phase imaging. The non-contrast CT images are ideal for detecting calculi. Detection and characterization of renal masses is done with a combination of unenhanced and nephrographic-phase imaging.
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The excretory-phase images are helpful in evaluation of the urothelium. Three-dimensional (3D) reformation of the excretory-phase images can produce images that mimic the appearance of intravenous urograms, thus providing images in a format which is very useful to referring clinicians.CT urography combines the benefits of excretory urogr aphy with those of cross sectional imaging in to a single study which depicts the renal parenchyma, collecting system and ureters. This technique is based on the acquisition of non-enhanced and enhanced CT scans of the abdomen and pelvis, including the essential acquisition of thin section helical CT scans of the urinary tract during the excretory phase of enhancement.
Multiplanar
- dimensional and
- dimensional refor mation images are produced from axials our ce images during the excretory phase
CTurography offers
Several advantages for imaging of the urinary tract : single breath hold coverage of t he entire urinary tract with absence of respiratory mis registration, rapid imaging with optimum contrast medium opacification and reduced partial volume effect as appropriate slices can be selected from the volumetric data
Greater speed of acquisition and higher resolution images are the advantages offered by Multi-detector row CT over single-detector helical CT.
There are various documentations on the findings of CTU mostly from developed countries with relatively scanty reports from developing countries. CT urography for patients who had clinical symptoms that highly suggested urinary tract abnormalities as well as the diagnostic value of CT urography were evaluated with the aim of documenting the different urologic pathologies seen in a tertiary care hospital (CHCC Lucknow). The purpose of study is to evaluate the role of multi-detector CT urography in the spectrum of urinary diseases.
AIM OF THE STUDY
To evaluate the role of CT urography in a spectrum of diseases of the urinary tract.
OBJECTIVE OF THE STUDY
- To describe the findings of CT urography in a spectrum of diseases of the urinary system.
- To study the most common etiology of hematuria in our set up.
REVIEW OF LITERATURE
Mahmoud AA et al (1) found out that CTU could be trustingly used as a very sensitive diagnostic one-stop shop imaging tool in patients with clinically suspected ureteric lesions like calculi, trauma etc.
Ahmed Moawad MM et al (2)MDCTU enabled an accurate diagnosis of the level of obstruction and its etiology, including nephroureterolithiasis, pelviureteric junction stenosis, ureteric strictures, ureteric injury, retroperitoneal fibrosis, and pelvic masses.
Gupta et al(3) conducted a study to evaluate efficacy of MDCT urography in various urinary tract abnormalities. Non contrast CT examination diagnose all cases of urolithiasis, pre and post contrast CT urography is required is non urolithiasis group for better delineation of soft tissue lesions
Song JH et al(4) assessed the utility of contrast enhanced CTU in patients with urinary calculi and it was found out that contrast enhanced phase was necessary in 84% of examinations to make out the specific diagnosis of hematuria because important pathologic changes are seen only after contrast enhanced phase
Cowan et al (5) performed CT urography in 106 patients with painless hematuria and it yielded a sensitivity of 97% and specificity of 93% in detecting upper urinary tract urothelial tumors. The study legitimized the CTU usage in spotting upper urinary tract urothelial tumors.
In a pilot study conducted by Jinzaki M et al(6)., contrast enhanced CT was performed in 59 patients with bladder tumors. CT with Multiplanar Reformation depicted bladder tumors with a sensitivity of 90% and no false positive findings . The outcome of the study showed that contrast enhanced MDCT has specificity for the detection of bladder tumors.
Another study executed by McTavish JD et al (7) in 51 patients with hematuria /suspected renal mass applied several protocols for illustration of the urinary collecting system and concluded that CT urography with supplemental saline infusion reliably delineates the opacified urinary collecting system
In a study by Chow LC et al (8), CT urography was performed on 500 patients (327 patients with painless hematuria) for urinary tract abnormalities and conclusion was drawn that CT urography spotted all proven cases of renal cell carcinoma asserting high sensitivity and specificity.
In retrospective study by Maheshwari et al (9), 200 patients underwent a study on CT urography and a sensitivity, specificity and accuracy of 100%,99%,99% was obtained for upper urinary tract cancers respectively.
Elliot K. Fishman et al (10)illustrated the importance of early phase imaging through the bladder, which is often the most sensitive technique for detecting subtle urothelial thickening, nodularity and hyper-enhancement that may suggest the presence of an underlying tumor.
MATERIALS AND METHODS
Source of data:
The proposed study will be conducted in the Department of Radiodiagnosis at Command hospital (Central command), Lucknow. All the patients falling in sampling frame bound by inclusion and exclusion criteria will be included in the study. Demographic details and clinical profile of the patients will be noted at the time of enrolment in the study
Study design:
Hospital based prospective observational study.
Sample size & duration:
The minimal sample size required is 50 cases for satisfactory statistical analysis. The study will be done over a period of 1 years from Feb 2019 and data will be collected during this period from all the patients who undergo CT urography investigation for various urinary tract diseases.
Statistical analysis:
- Data will be depicted in the form of tables and charts.
- Appropriate statistical tests like Paired T test and other non parametric tests will be used.
Collected findings will be analyzed by correlating it with laboratory, surgical, clinical data.
Method of data collection:
CT Urography study will be performed using PHILLIPS BRILLIANCE 16 CT Machine with a 16 slice scanner using the following imaging sequences. The patients will undergo a 3 phase CT examination after obtaining informed consent in written form. First phase is the initial non-contrast phase. Second phase is the nephrographic phase, which will be acquired following a delay of 40-50 seconds after administration of 60-80 ml of intravenous iodinated contrast, to evaluate the renal parenchyma. Followed by the pyelographic/excretory phase which will be taken 15 -20 minutes following administration, to evaluate the urothelium from the pelvi caliceal system to the bladder.
The follow up diagnosis will be established on the basis of histopathologic findings or the findings at a urological procedure (cystoscopy, ureteroscopy and retrograde pyelography) wherever applicable.
Inclusion criteria:
- Patients with urinary symptoms like hematuria, obstructive urinary tract disease, suspected neoplasms, and trauma.
Exclusion criteria:
- Deranged biochemical parameters like blood urea and serum creatinine etc.
- Cardiac failure
- Pregnant and lactating patients
- Previous history of anaphylactic.
Clearances and Approval:
Approval for conducting the study will be obtained from Institutional Ethical Committee of Command Hospital (Central Command), Lucknow.
Informed consent will be obtained from all patients enrolled in the study.
REFERENCES
- Mahmoud AA et al, Role of CT urography Alexandria University Faculty of Medicine. Production and hosting by Elsevier B.V. Alexandria Journal of Medicine, Volume 54, Issue 3, September 2018,
- Ahmed Moawad MM et al, The role of multidetector computed tomography urography in the evaluation of obstructive uropathy. Menoufia Med J 2015;28:554-8
- Gupta R, Raghuvanshi S Multi–detector CT Urography in the diagnosis of urinary tract abnormalities. Int J Med Res Rev 2016;4(2):222-226. doi: 10.17511/ijmrr.2016.i02.016.
- Song JH ,Beland MD, Mayo-Smith WW. Hematuria evaluation with MDCT urography.AJR 2011 ;197:W84-W89
- Cowan NC, Turney BW ,Taylor NJ, McCarthy CL, Crew JP ,Multi Detector CT urography for diagnosing upper urinary tract urothelial tumor. BJU international2006;99:1363-1370
- JinzakiM,TanimotoA,ShinmotoH,HoriguchiY,SatoK,KuribayashiS,Silverman SG Detection of bladder tumors with MDCTU .AJR 2007; 188:913-918
- McTavish JD, Jinzaki ,Zon KH, Nawfel RD, Silverman SG, Multidetector row CT urography : comparison of strategies for depiction of urinary collecting system. RSNA 2002:225:783-790
- Chow LC, Kwan SW, Olcott EW, Sommer G split bolus MDCTU with synchronous nephrographic and excretory phase enhancement. AJR 2007;314-322
- MaheswariE,O’malley ME, Ghai S, Staunton M, Massey C, Slit Bolus MDCTU :Upper tract opacification and performance for upper tract tumors in patients with hematuria.AJR2010;194:453-458
- Bladder Malignancies on CT: The Underrated Role of CT in Diagnosis, Elliot K. Fishman Citation: American Journal of Roentgenology. 2014;203: 347-354. 10.2214/AJR.13.12021
- Purpose of Study:
The aim of this study is to describe the role of CT Urography in spectrum of urinary tract diseases and to study most common etiology of hematuria in our setup.
- Procedure of Study:
All patients presenting in the department of radiodiagnosis of Command Hospital, Central Command, Lucknow with urological symptoms like hematuria ,neoplasm, injury, calculus etc in a time period of twelve months will be enrolled in this study after providing informed consent to participation. These Patients will be evaluated by Triple phase CT Urography. Surgical, HPE, urological findings of urinary tract will be obtained for correlation with CT Urography findings.
- Complications/Risks:
CT Urography uses high radiation dose (`~ 2300-2500 mGy*cm) and there is always a slight risk of malignancy associated from excessive radiation exposure. However the benefit of accurate diagnosis will generally outweigh the risk.
The risk of serious allergic reaction to contrast materials that contain iodine is extremely rare, and radiology department & hospital is well-equipped to deal with them.
- Benefits from study:
CT urography is helpful in evaluating renal parenchyma in one relatively non invasive comprehensive examination.
It combines the benefits of excretory urography and cross sectional imaging in one study delineating the collecting systems and ureters and also offers several advantages in imaging the urinary tract.
- Rights to Participation:
The participation in the study is totally voluntary and on the will of the participant. The participant can enroll or withdraw from the study without affecting the quality of healthcare being provided in the hospital.
- Compensation:
No compensation will be provided to the participants for their participation in the study.
- Confidentiality:
All the information obtained shall be kept confidential except for use for the research purposes. In any publication arising out of the research, none of the subjects will be identified.
CONSENT
I have been explained the objectives and procedures of the study and have been given the opportunity to question and have them answered to my satisfaction. I know that my participation in the study is voluntary and does not include any compensation for participation in the study. I have been told that I can withdraw from the study at any point without assigning reasons for so and without affecting my treatment at the hospital.
